Part I
1. I’m tired all the time
2. I have pain at night
3. Things are getting me down
4. I have unbearable pain
5. I take tablets to help me sleep
6. I’ve forgotten what it’s like to enjoy myself
7. I’m feeling on edge
8. I find it painful to change position
9. I feel lonely
10.I can only walk about indoors
11.I find it hard to bend
12.Everything is an effort
13.I’m waking up in the early hours of the morning
14.I’m unable to walk at all
15.I’m finding it hard to make contact with people
16.The days seem to drag
17.I have trouble getting up and down stairs and steps
18.I find it hard to reach for things
19.I’m in pain when I walk
20.I lose my temper easily these days
21.I feel there is nobody I am close to
22.I like awake for most of the night
23.I feel as if I’m losing control
24.I’m in pain when I’m standing
25.I find it hard to dress myself
26.I soon run out of energy
27.I find it hard to stand for long (e.g.‚ at the kitchen sink‚ waiting for a bus)
28.I’m in constant pain
29.It takes me a long time to get to sleep
30.I feel I am a burden to people
31.Worry is keeping me awake at night
32.I feel that life is not worth living
33.I sleep badly at night
34.I’m finding it hard to get on with people
35.I need help to walk about outside (e.g.‚ a walking aid or someone to support me)
36.I’m in pain when going up and down stairs or steps
37.I wake up feeling depressed
38.I’m in pain when I’m sitting
Part II
Is your present state of health causing problems with your. . .
39.Job or work? (That is‚ paid employment)
40.Looking after the home? (Examples: cleaning and cooking‚ repairs‚ odd jobs around the home‚ etc.)
41.Social life? (Examples: going out‚ seeing friends‚ going to the pub‚ etc.)
42.Home life? (That is: relationships with other people in your home)
43.Sex life?
44.Interests and hobbies? (Examples: sports‚ arts and crafts‚ do-it-yourself‚ etc.)
45.Holidays? (Examples: summer or winter holidays‚ weekends away‚ etc.)
EL= energy level‚ P = pain‚ ER =emotional reactions‚ S = sleep‚ SI = social isolation‚ PA = physical abilities.
Yes‚ No
EL= energy level (items 1‚ 12‚ 26)‚ P = pain (items 2‚ 4‚ 8‚ 19‚ 24‚ 28‚ 36‚ 38)‚ ER =emotional reactions (items 3‚ 6‚ 7‚ 16‚ 20‚ 23‚ 31‚ 32‚ 37)‚ S = sleep (items 5‚ 13‚ 22‚ 29‚ 33)‚ SI = social isolation (items 9‚ 15‚ 21‚ 30‚ 34)‚ PA = physical abilities (items 10‚ 11‚ 14‚ 17‚ 18‚ 25‚ 27‚ 35)
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